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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT SAN JOAQUINCOUNTY-KMLICHEALTH! t�IIWAZE`TON AVE., STOCKTON, CA ENVIRONMENTAL HEALTH DIVISION Telephone (209) 466-6781 SPECIAL PE IT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 441 Charter Way city stocktrtn Lot Size PM Owner's Name ARCO Products Company Address P.O. Box 5811 Phone (415)571 -2434 Contractor Western Strata Exp}gegjion P.O. Box 1664 License No, 552198 Phone (916)373-1118 TYPE OF WELL/PUMP: NEW WELL }~I WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER XX GW Well ;Vapor W( 11 DISTANCE TO NEAREST: SEPTIC TANK )50 SEWER LINES " CSD DISPOSAL FLD.N_ PROP. LINE NA FOUNDATION <?0 AGRICULTURE WELL >50 OTHER WELL >50 PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 11Manteca Dia. of Well Excavation O Dia. of Well Casing 41' ❑ Domestic/Private XX Gravel Pack ❑ Tracy Type of Casing PVC Specifications (1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout bentonite/ em I I Irrigation _Approx. Depth XX Eastern Surface Seal Installed by dr111P - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 \ Depth Filler Material (Below 501 -J TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION I I (No septic system availablewithin 200 feet.) it public sewer is Installation will serve: Residence_ Commercial_ Other ee Number of living units: _ Number of bedrooms C Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No entgsp PKG. TREATMENT PLT. ❑ MefFtyj"`h f falx Distance to nearest: Well Foundation PropertyRiE .t+r-nic-n LEACHING LINE ❑ No. 6 Length of lines Total leng%..,j a FILTER BED ❑ Distance to nearest: Well FoundationR 1V�e4UlN COUNT(' l PmRe Y. . � - - SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health oio District. � �IOWA;S Home owner or licensed agent's signature certifies the following: "I certify that in the pe h -Cii � employ any person in such manner as to become subject to workman's compensation la 1 ature certifies the following: "I certify that in the performance of the work for which this permit is issued, I� ensa- tion laws of California." SPECIAL + EWT The applicant must 1 all required in actions. Complete drawing o�everse side. L/ Signed X wwr Title:,((_ ^ ^' �"ol Date: '� 42- FOR DEPARTMENT USE ONLY Application Accepted by / Date Area Pit or Grout Inspection by Date _ g�p4,Final Inspection by Date Additional'Co /1a A`2&*Z Bb �B11,166 A,a D4 wa- ❑ Stk 466-6781 ❑ Lodi 1 ❑ Men eca 823-7104 ❑ racy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 257 U'/J� FEE AMOUNT DUE AMOUNT REMITTED CASH RECEI D BV DATEiin INFO yt ^ 4 EH 1334 IREV.1ix51 ') !'1 / � /� EH 14-M VVV